Volunteer Application Form

Transcription

1 Laugh Imagine Dream Joy Lorem Ipsum Dolor [Street Address] [City], [State][Postal Code] [Recipient] Volunteer Application Form Carol Jean Cancer Foundation, Inc. Camping Programs: Camp Friendship, Teen Scene, Lori s Junior Day Camp, Beth s Children, Brothers and Sisters Together, STRETCH, Teens N Twenties. (410) Cleos Ct. Columbia, MD cjcf4kids@live.com

2 Camping Programs Staff Mission Statement Our mission is to provide many opportunities for the children to form friendships that will last a lifetime. Together we will create an environment full of love and fun. We will support each other with open arms and love in order to create a safe and friendly community. We will strive to expand our boundaries by stepping outside of our comfort zone and create an atmosphere conducive to learning and growing through laughter, patience, and respect. Programs Sponsored By: Carol Jean Cancer Foundation, Inc Cleos Ct * Columbia, MD * * Fax cjcf4kids@live.com Carol Jean Cancer Foundation, Inc. provides year-round programs and services free of charge for children with cancer and their families. Member of COCA (Children s Oncology Camping Association, International) Registered with the Secretary of State of the State of Maryland as a Charitable Organization A Not-for-Profit Corporation under Federal Tax Exemption 501 (3) of the Internal Revenue Code Federal Employer ID No

3 A Message From Beverly E. Gough, President of the Carol Jean Cancer Foundation, Inc. and Tommy Gough, Director of Camping Programs. On behalf of our special children and their families who benefit from the programs of the Carol Jean Cancer Foundation, Inc. and the volunteers who work so hard throughout the year to make it all possible, we would like to thank you for your interest in pursuing a volunteer position. Our camping programs offer a blend of fun and health care. Medical personnel at the camp are available at all times, as are trained instructors who supervise traditional camp activities such as swimming, canoeing and kayaking, sports and games, arts and crafts, etc Our goal is to have each camper treasure this magical week of camping with us. There s no question that volunteering for our camping programs is hard work but we promise you an experience of a lifetime! Brothers & Sisters Together Overnight camping programs for children ages 7-17 who have a brother or sister with cancer (Monday Friday). The Seashell Connection A pediatric cancer hotline. Carol Jean Cancer Foundation, Inc. Camping Programs Descriptions Free of Charge Camp Friendship Overnight camping program for children ages 7 17 with cancer (Sunday Friday). Teen Scene Teen Scene offers a camping experience and gatherings throughout the year for Camp Friendship teens to share their feelings and enjoy friends. The Altar Vision The Altair Vision gives parents a helping hand in fulfilling the special dream of a young person stricken with cancer. Times for Moms &: Dads & Mom s Weekend An opportunity for parents to meet socially with other parents of children with cancer. Project STRETCH Stand tall Reach for Education Climb High! Lori s Jr. Day Camp Day program for children ages 3 7 with cancer (Monday Friday). Beth s Children Overnight camping program for children 7-17 who have a parent with cancer or have lost a parent to cancer (Sunday Friday). Project STRETCH provides assistance to CJCF campers who have graduated from high school in areas such as job search, resume writing and letters of recommendation plus a fun opportunity to stay in touch with camp friends after age 18! Teens N Twenties (T N T) This program will include a travel camp, weekend programs, and support activities for young adults ages who have been touched by cancer. NOTE: Applications are available to any person 18 years and older without regard for race, sex, religion, or national origin. Applications are subject to the approval of the Program Committee. To be considered, please fill out the entire application. Be sure you have answered all questions. After applications have been reviewed, final applicants will be interviewed. Carol Jean Cancer Foundation, Inc. provides year-round programs and services free of charge for children with cancer and their families. Member of COCA (Children s Oncology Camping Association, International) Registered with the Secretary of State of the State of Maryland as a Charitable Organization A Not-for-Profit Corporation under Federal Tax Exemption 501 (3) of the Internal Revenue Code Federal Employer ID No Cleos Ct Columbia, MD cjcf4kids@live.com

4 Camp Friendship Packing List What to bring: o Medications o Swim Suits (1 piece) o Plenty of T-Shirts & Shorts o Plenty of Socks & Underwear o 2 pair long pants o Pajamas/Sleepwear o 2 sweaters/sweatshirts o Sneakers/Hiking Boots o Flip Flops/Sandals o Rain Jacket o Towels for shower & pool o Soap & Shampoo o Toothbrush & Toothpaste o Brush or Comb o Sunscreen Optional items: o Camera & Film o Pillow o Reading Material Items you should not bring: o I Pod/MP3 players o Handheld electronic games, music players, etc. o Food, candy, gum, etc. * Please keep in mind that you will be sharing a cabin with 9 other people and expensive items should be left at home. Camp is a place to get dirty and have fun. Please pack accordingly. CJCF is not responsible for lost items. o Insect Repellent o Hats & Sunglasses o Flashlight & Batteries o Laundry bag o Backpack

5 Carol Jean Cancer Foundation, Inc. - Volunteer Application Last Name First Name Middle Initial Today s Date Home Address City/State/Zip School Address City/State/Zip Home Phone School/Business Phone Cell Phone Address Birthday Age Male/Female Social Security Number Program you wish to volunteer for: Camp Friendship Teen Scene Teens N Twenties Lori s Jr. Day Camp You must be 18 or older for all programs. Camp Counselor Position Job Description: 1. Assigned to a cabin with a group of campers, responsible for their daily supervision throughout the camp session. 2. Responsible for following the daily schedule of activities as set forth by weekly schedule. Boy s Counselor: Ages 7 9 Ages Ages 13 & up Girl s Counselor: Ages 7 9 Ages Ages 13 & up Camp Medical Staff Position. Must be licensed in Maryland (additional forms will be sent for this category): Doctor Nurse Nurse s Aide Other Specialized field of medicine: Do you have a private practice? YES NO With what hospital(s) do you have affiliation? In what state(s) are you certified to practice? I am able to volunteer for: The full week of camp Shifts Do you cover personal insurance that will cover you at our site? Yes No Note: A copy of your medical license(s) will be required for our files.

6 CURRENT CLASSIFICATIONS: Completion Date Expiration Date Red Cross First Aid: Standard Advanced CPR: 4 hour Adult/Child 8 Hour Professional Emergency Medical Technician (Level) Advanced Lifesaving: Water Safety Instructor: Lifeguard Training Standard Instructor Canoeing: Basic Instructor Sailing: Basic Instructor Boating: Basic Outboard Instructor IMPORTANT: Copies of all current classifications MUST ACCOMPANY THIS APPLICATION. Do you carry Family Medical/Health Insurance? YES NO Carrier REFERENCES: Policy Number Name Relation to you Address City/State/Zip Phone Name Relation to you Address City/State/Zip Phone Name Relation to you Address City/State/Zip Phone Name Relation to you Address City/State/Zip Phone Where did you learn about the programs of the Carol Jean Cancer Foundation, Inc? Do you know anyone involved with the Carol Jean Cancer Foundation, Inc.? If I am accepted as a volunteer, I agree to complete the full training program. The information provided by me in the Volunteer Application is true and complete to the best of my knowledge. I understand that if I am selected, any false statements will be considered as cause for possible dismissal. You are hereby authorized to conduct any investigation of my personal history, as related to the position for which I have applied. Signature Date FOR ALL APPLICANTS: Please attach a biographical sketch of yourself telling us why you are interested in volunteering for one of our programs. Mail application to: Carol Jean Cancer Foundation Cleos Ct Columbia MD Teaching Fellows mail application to: 605 N. Pine St. Charlotte, NC cjcf4kids@live.com

7 Carol Jean Cancer Foundation, Inc. - Volunteer Medical Form Name Date of Birth Age Sex Home Address City/State/Zip Business Address City/State/Zip In case of Emergency please contact: _Phone: HEALTH HISTORY: (Answer YES or NO) For all questions answered YES, please give date of diagnosis and current management below. Frequent Ear Infections Heart Defect/Disease Convulsions/Seizures Diabetes Asthma High Blood Pressure Cancer Bleeding/Clotting Disease Kidney Disease Visual & Hearing Impairment ALLERGIES: Hay Fever Poising Ivy, etc Insect Stings Penicillin Other DIETARY RESTRICTIONS/NEEDS: DISEASES: Chicken Pox Shingles Measles German measles Mumps Please list any other medical problems, conditions, or disabilities: Please list any operations or serious injuries: IMMUNIZATION HISTORY: Give date of last Tetanus shot ONLY. Immunization records are required. Please record the date, month, & year, of basic immunization and most recent doses: VACCINES Date of Basic Immunizations Date of Booster DPT Tetanus Booster (must be current) Oral Polio (Sabin) * TOPV Measles (hard measles, red measles, Rubeola), Rubella (German measles, 3-day), (MMR) Other MUST FILL OUT: Medical/Hospital Insurance Carrier Policy or Group Number Primary Physician Primary Dentist/Orthodontist Phone Phone

8 Carol Jean Cancer Foundation, Inc Cleos Ct * Columbia, MD * * Fax CONSENT FOR MEDICAL TREATMENT I, the undersigned hereby grant permission to the medical staff at CJCF Programs to administer routine and prescribed medication, as well as any emergency care as required. I have provided the camp with all known drug allergies, list of current medications and a medical history. In the event a relative or spouse cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure proper treatment including hospitalization, medication, anesthesia and/or surgery. I also give permission for the staff of CJCF Programs to provide transportation if needed. Signature Parent s Signature (if under 21 years old) Date * * * * * * * * * * * * PHOTOGRAPHIC AND VIDEO CONSENT FORM I consent that photographic and/or video pictures may be taken for the purpose of obtaining publicity for CJCF Camping Programs. I also consent to be interviewed for T.V. or newspaper reports while attending CJCF Camping Programs. Signature Parent s Signature (if under 21 years old) Date * * * * * * * * * * * * FOR ALL VOLUNTEERS UNDER THE AGE OF 21, PARENTS OR GUARDIANS MUST SIGN Print Name Signature Date Relationship to Volunteer cjcf4kids@live.com Website: